Chewing tobacco is a form of oral smokeless tobacco. Smokeless tobacco is used to describe the tobacco that is used in un burnt form. Tobacco used for this purpose is prepared by harvesting the tobacco leaves when they turn yellow and brown spots start appearing on the leaves they are left in the fields for uniform drying.The aging time for leaves for making chewing tobacco is one to three years. They are then tied into bundles and moistened with water and molasses and are stored for fermentation for a couple of weeks .The bundles are then separated and dried again and leaves are cut into different sizes
Chewing tobacco can be used itself or as an ingredient to other products such as betel quid (paan) The preparations are placed in the mouth, cheek or lip and are sucked or chewed.The most common preparation of chewing tobacco used are
It is commercially prepared. The product constituents are leaf tobacco, sweetener and liquorice Loose cigar leaves are air-cured and steamed. It is then cut into small strips of shredded tobacco. Licorice is added to give flavour
It is made from enriched tobacco leaves collected from the plant, immersed in a mixture of liquorice and sugar and pressed into a plug.
This type of tobacco is hand made. Air crued tobacco leaves are treated with a tar like tobacco leaf extract and are twisted into a rope like strands that are dried.
It is dry commercial preparation containing areca nut, slaked lime, powdered tobacco, catechu and condiments. The same mixture without tobacco is called paan masala .Both Guthka and paan masala are attractively packed and widely available. It is highly addictive and is used as a mouth or breath freshener(21) Most common brand names are Manichand,Tulsi and parag
Betel Quid (Pann)
Paan consists of betel quid leaf, areca nut, slaked lime and catechu. Flavouring agents such as mentol, champhor, sugar,rose water, aniseed, mint water and other spices are added according to individual and regional preference. Chewing tobacco is also used as an ingredient in betel quid (paan).However paan can also be used without tobacco. Tobacco is used as raw, sundried and roasted that is finely chopped into small pieces or powdered. To make the quid slaked lime and catechu are smeared on a betel leaf. The leaf is folded in a funnel shape and tobacco and other ingredients are added. The top is folded over resulting in a quid which is placed in the mouth.
.It is prepared by cutting tobacco leaves into small pieces and boiling them in water with slake lime until water evaporates. It is then dried and coloured with the vegetable dyes. Spices and perfumes are added. Zarda can be chewed itself with areca nut or added as an ingredient in paan. Most common brands available are Baba, bharat, gopal, Betel quid Parag.
It is thick tobacco paste available in the form of granules and pellets To prepare Qiwam the tobacco leaves are soaked and boiled in water, flavoured with spices and additives and stirred well. I then strained and dried into a paste from which granules and pellets are made.It is either placed in the mouth and chewed or used in betel quid.
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Although the use of oral smokeless tobacco product has been existed for thousand of years in South America and South East Asia, the products became popular in other parts of the world as well [FS 00] The frequency of its use varies considerably not only across the countries but also within the countries according to sex, age, ethnic origin and socioeconomic status of the people.Oral smokeless tobacco use is widely prevalent in South East Asia. According to WHO figure in 2004,17% of the total population in Southeast Asia uses oral smokeless tobacco and 95% of these people belong to India and Bangladesh.[NML]
Chewing tobacco is the most common form of oral smokeless tobacco used in South East Asia. It is used in a variety of forms; betel quid chewing (paan), leaf alone, leaf with lime and tobacco, and areca nut preparations. Historical evidence has indicated that the habit of paan chewing has been existed for 2000 years and is being used from year 437AD . About 600million people are estimated to chew paan in Southeast Asia and tobacco is an important constituent of paan especially for users in Bangladesh, India and Pakistan 
The use of these products was dropped in Europe and North America but an opposite trend has been observed for the last few decades particularly among people under the age of 40 years. These products are used as an alternative option to cigarettes and other smoking products and are considered to be of negligible risk to health .
Demographic context of South-Asian UK Community
According to 2001 census number of South Asians in the UK were 2,010,541 that make up 4% of the total UK population. Indians were the largest figures 1,028,539 (1.8%) followed by Pakistanis and Bangladeshis with 706,752 (1.3%) and 275,250 (0.5%) respectively. 2004 estimate shows that number of British Asian community in the UK is 2,7999,700.
Asians are present in most towns and cities of the UK. The largest concentration of Indians are in west London, Leicester and west Midlands Pakistanis are evenly distributed in the UK with greater concentration in Birmingham, Lancashire ,Yorkshire, Greater Manchester and greater London. Most of the Bangladeshis live in East London in Tower Hamlets where they make up 33% of the total borough population.
Recent tobacco control strategy & Support for chewing tobacco users
For many years the users of chewing tobacco in some areas of the UK have been treated by local stop smoking services on the grounds that individuals seeking help for tobacco use of any kind should be offered support within NHS. Since April 2009,there is no clarification that tobacco chewers can be included in the monitoring data for NHS Stop Smoking Services 5 So there is little incentive for the services to treat tobacco chewers. However certain locally established services are working to help people quit. There is no rigorous search on different types of smokeless tobacco products used in UK(8) All this has resulted in raising the concerns that chewing tobacco has received little attention in the UK compared with cigarette smoking, the predominant form of nicotine use. As a result, there are concerns that tobacco chewers may be unaware of the health risk
However in the latest DOH guidelines “A smoke free future: a comprehensive tobacco control strategy for England” the government has highlighted the harmful effects of smokeless tobacco and has stressed upon the implementation of certain regulations regarding its use in the UK. It has been considered to extend the legislation on pictorial health warnings to smokeless tobacco products and to label the products clearly. In addition it will be tried to ensure that the legislation on the labelling, display and sale are enforced. Work will be done to get a clear picture of the current market. UK Government will continue to support the current European prohibition on the sale of ‘snus’.
Regarding support and advice for the current users of smokeless tobacco government will work with NCSCT to develop and implement cessation packages and care pathways. Efforts will be made for these pathways to be embedded in the community and to become sustainable. Additional support will be provided by communication strategies to the users of chewing tobacco and health and social care professionals and workers to highlight the health risks associated with the use of such products and support and methods available to stop them.
The literature search was conducted using the online databases given in table 1
It is a major biomedical data base that covers a wide range of articles on clinical and experimental human medicine ,health policy management and public health
Medline is good source of biomedical and clinical medical literature.
For the systematic reviews of the studies.
Boolean operators (AND, OR) were used and search was conducted in three different categories using the key words given in table
The searches were limited by:
English language documents only
No study from date before 1990 was included
The initial searches on Medline and EMBASE produced 1209 papers on chewing tobacco OR smokeless tobacco The search was then restricted to focus on chewing tobacco only and found 245 articles. The review was highly specific regarding the use of chewing tobacco in UK,so all the studies conducted outside the UK were excluded and the number was reduced to 16 only.
Searching for the harmful effects of chewing tobacco OR smokeless on different database revealed 72 papers from all over the world. Nearly half of these papers had no description of chewing tobacco and were excluded.
Search for the attitudes towards the use of chewing tobacco was very limited and produced only 6 papers globally. Limiting the search further in UK found nothing on this topic.
The studies found were reviewed for the relevant information under the following headings
The use of chewing tobacco in the UK
Use of chewing tobacco in the UK
Research has suggested the widespread use of areca nut mixed with smokeless tobacco amongst Asian ethnic communities residing the western world. Of the 2.4 million South Asians in the UK,27-98% are users of smokeless tobacco depending on the community and sexwhile chewing tobacco is the most common form of smokeless tobacco used in the UK.
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Studies in the UK have found a high prevalence of betel quid (paan) chewing in South Asian communities among both sexes in all age groups and increasing incidence with the age [14,15,16,17,18] [40,41,42,43,44] The habit of paan chewing varies between 66% to 95% within Bangladeshi UK communities whilst in Indian and Pakistani it is 15% and 75% respectively .Bangladeshi women are distinct from other minority ethnic groups in their tobacco use as most of it is derived from chewing tobacco (16%) rather than cigarette smoking (2%). However the reporting of chewing paan with and without tobacco varies among Bangladeshi women living in Britain It has been found that out of 75-90% of Bangladeshi women chewing paan, 50-80% use tobacco in their paan The first large study conducted in Birmingham to investigate the use of betel quid and tobacco chewing among Bangladeshi community in the UK found that 92% of male and 96% of female chewed betel quid on daily basis and the percentage of male and female users of betel quid and chewing tobacco increases with the age..
Furthermore It has been found from the studies that in Bangladeshi community the number of the women chewing tobacco with betel quid is higher than men and 37% of male were reported to chew betel quid with tobacco whilst 81% of women did so. In another study in west Yorkshire 95% of women were chewing paan of which 89% reported to add tobacco. Similarly Health education authority (HEA)survey for health and lifestyle in ethnic minority 2004 has found that the prevalence of chewing paan in 50-74 years age group was 76% for women and 62% for men of which the frequency of adding tobacco was 58% and 31% respectively. Same results were revealed in Tower Hamlet in 1999 where 86% of women and 71% of men chewed betel quid, and the frequency of adding tobacco was 64% for women and 42% for men .
On the other hand in two other studies conducted in Tower Hamlet, London and inner city of London the prevalence of chewing tobacco among Bangladeshi women was low;48.5% and 43% respectively[20,22].[39,38] The actual prevalence is thought to be higher as the reasons demonstrated for this low prevalence is cross-sectional study design that provides only a snapshot of the current picture and is unable to describe the actual behaviour. Other possible reasons include the study sampling and questionnaire wording. It has been later on found that the tobacco use in chewing paan is under reported by Bangladeshi women. In another study nearly half of the women in the sample undisclosed their personal tobacco use 1. Likewise in another study of betel quid use among first and second generation of women in London, the prevalence ranged between 25% to 33% and 49% of these women were reported to add tobacco. The possible explanation given for this low finding is the smaller sample size and the age range selected for this study was narrow (18-39)years. It did not include the age group over 45 years where the prevalence of betel quid use is highest 
The habit of the paan chewing is found to be started in this community before the age of 15 years[16,18][44,42] and some times it is acquired at a very early age ( as early as 5years) but mostly in early teen age between 11 and 15 years[24,11][4,5] Another research in East London has also found a high level of regular paan use, both tobacco containing and tobacco free, among the young Bangladeshi adolescents of 12-14 years of age. Most considerable fact is that only a third of these young people knew the association between tobacco containing paan and oral cancer(11)
The different types of chewing tobacco used in the UK are similar to those used in Southern Asia and include;Guthka,zarda,dried whole and chopped tobacco leaves and tooth cleaning powders(abrasive powdered tobacco with aromatic ingredients)These products are available in the market with different branded names. Such as for Guthka it is Manikchard and Tulsi mix. Zarda is available as Hakim pury,DulalMisti and Baba Zard gulabi Pati.The name given to teeth cleaning powder is Quardir Gull.
Some of these products are used in conjunction with paan.
All these chewing tobacco products used have at least a detectable level of some of the carcinogens. One type of zarda product ‘Hakim Pury’ is of special concern as it is found to have high levels (29.7µg/g) of carcinogens, nitrosamine (TSNA) and is putting the life of the users at risk. Different level of toxins and nicotine content has also been found in Guthka and tooth cleaning powder..
It has been found that gutka and paan are commonly sold in the UK without health warnings.’The UK Children and Young Persons ( protection from tobacco) Act’1991 states that it is an offence to sell the tobacco products to people under the age of 18 years and tobacco containing gutka and paan fall in this category. If legislations are not enforced .there is a risk that this problem would not remain confined to South Asian community but also spread to other ethnic groups.11
Effects of the treatment
One pilot study conducted in London in UK has described the effect of NRT patch along with brief advice and encouragement on the reduction in the use of chewing tobacco in South Asian community. The report of this study suggested that NRT helped volunteers to give up chewing tobacco use in moderately dependent users of chewing tobacco whilst advise only was helpful for those with low dependency. There was a great reduction in the salivary cotinine level in the group of volunteers treated with NRT patches (24) According to a report 67% of the Bangladeshi women have declared a desire to quit the use chewing tobacco products.5
The habit of chewing tobacco is associated with a number of risk factors some of which are fatal whilst the others are injurious to heath.
Oral cancer is a common malignancy among people who smoke and chew tobacco and is the 11th most common cancer that makes up 3 to 4% of all cancers, worldwide. 300,000 new cases of oral cancer occur and is responsible for 200,000 deaths, each year, globally[28,29]. (29,33)
There is a significant difference in the prevalence of oral cancer among different ethnic groups and is found to be related to their cultural habit such as chewing of tobacco, areca nut and betel quid. It is the most common form of cancer in India and South Asian countries and account for 40% of total malignancies with high frequency in Bangladesh, India and Srilanka.
A number of studies conducted in Asia Pacific have shown an increased risk of oral cancer among betel quid (paan)chewers. The presence of tobacco in betel quid further increases the risk.
The first cohort study to examine the risk of oral cancer in women chewing tobacco was conducted in a rural costal area in Kollam district of Kerala over a period of 15 years from 1990 to 2005.The results revealed a strong association between daily usage of chewing tobacco and the incidence of oral cancer in women and the risk was 9.2 folds higher among women who chew 10 times or more in a day. The risk also increased with the duration of chewing in the first 20 years.(29)
The incidence of oro-pharyngeal cancer is highest in India and is strongly related with the use of chewing tobacco[3,] A study in Bhopal has found an increase risk of oro-pharyngeal cancer whilst the risk of oral cavity cancer was increased up to six fold with tobacco quid chewing. The risk was found to be 66.1% for tobacco chewers for the development of oral cavity cancer
Another most recent review of the studies on the head and neck cancer has tried to explore the associated risk factors. The carcinoma of the oral cavity; oropharynx, larynx and hypopharynx was the focus of the studies. It has been found that the incidence of head and neck cancer is increasing in women chewing tobacco which is considered as a newly recognised risk factor of great concern(28) Chewing tobacco has been found as an independent factor associated with an increased risk of hypo-pharyngeal cancer in a clear dose response relationship(33)
The wide spread habit of chewing tobacco among South Asian community in the UK has raised concerns in public health authorities because of its harmful effects. There is a potential risk of oral and pharyngeal cancer among Asian immigrants living in the UK A systematic review of the studies conducted in Europe and North America has shown a consistency of their results in finding the association of chewing tobacco and oro-pharyngeal cancer thus suggesting the strength of this association
.Between 1998 to 2000, an average of 5,010 new cases of oral cancer were detected per year in the UK. In the year 2000, 2,073 new cases occurred. The mortality rate due to this disease is 40% which is higher than due to cervical and breast cancer. It is possible to prevent the mouth cancer by avoiding the risk factors and early detection as the Awareness about the early signs and symptoms of mouth cancer is very low in high risk patients in the UK population although it has not been found to be low about knowing chewing tobacco as a cause of oral cancer.(25)
Betel quid causes oesophageal cancer even without adding tobacco(18) and the addition of tobacco enhances it effect. Cancer of the oesophagus was higher in men in Assam who had been using fermented betel nut combined with any type of tobacco(19).These findings are supported by a systematic review that explored the association of chewing tobacco not only with the oral and oesophageal cancer and also with the squamous cell carcinoma of the lip, buccal cavity, tongue and floor of the mouth.
In a cross-sectional analysis in England and Wales it has been found that the mortality rate from hepatocellular carcinoma and liver cirrhosis is high among men from South Asian community which cannot be explained by their patterns of alcohol consumption but might partly be attributed to the direct effect of paan chewing with or without tobacco(16) Similarly another case control study conducted in Taiwan has found a modest but independent dose dependent relationship between the habit of chewing tobacco and liver cancer. Furthermore it has been found that the paan chewers infected with hepatitis B and C are at an increased risk of liver failure as compared to non chewers infected with the virus alone.(17).
The overall survival rate after the treatment of squamous cell carcinoma of the tongue at five and 10 years was 60% in people who did not chew tobacco whilst it declined to 40% in those who did so. Similarly relapse-free survival rate at 5 and 10 years was also higher for non chewers (63%) compared to those who chewed (42%) and was associated with high risk of loco-regional failure 
Tobacco smoking /chewing causes oxidative stress that is defined as “a sustained pressure of reactive oxygen species (ROS) in tissues.ROS are involved in the initiation of cellular free radical reaction and thus causing damage to protein, lipid, carbohydrate and DNA. If DNA damage is minor it can cause mutagenesis whilst severe damage will result in modifying the cell cycle”
A number of studies have been conducted to estimate the risk of pancreatic cancer associated with chewing tobacco and revealed conflicting results. “In 2008, a report from European Community ‘Scientific Committee on Emerging and Newly identified Health Risks’ (SCENIHR) on the health effects of smokeless tobacco  has stated that “All STP [Smokeless Tobacco products] contain nicotine, a potent addictive substance. They also contain carcinogenic tobacco-specific nitrosamines of differing levels. STP are carcinogenic to humans and the pancreas has been identified as a main target organ.”
Similar findings were reported in 2007 by International Agency of Research on Cancer (IARC) concluding “there is sufficient evidence in humans for the carcinogenicity of smokeless tobacco. Smokeless tobacco causes cancer of the oral cavity and pancreas.”
In contrast a systematic review in 2008 has demonstrated conflicting results with no effect of smokeless tobacco (ST) on risk of pancreatic cancer. However it has highlighted the limitation and weakness of the available data and has suggested for more evidence to determine the true relation. The number of exposed cases as compared to controls was small in the studies included for the review and there was a limited control for confounders as diet was not taken into account during analysis of risk from ST. The reliability of the base line exposure data was also doubtful in some of the cohort studies conducted over a period of 15 years as it has been suggested that there is considerable change in the use of smokeless tobacco over the long follow up period..
Although the relationship of chewing tobacco with different types of cancers has been revealed in different studies but the interpretation of meta analysis of these studies is difficult as there a number of shortcomings associated with them. The studies are of variable size, quality and design are not able to provide sufficient information. Other draw backs include; small number of cases exposed to chewing tobacco lack of histological confirmation, unclear description of inclusioin and excliusion criteria,no details of selection of cases. Furthermore some studies have not mentioned about the type of ST used, its frequency and duration of use. Chewing tobacco products vary by country and overtime and older studies show an increased risk which may be not be the same for modern studies because of less nitrosamine level in modern products.
Pre neoplastic disorders
Oral submucous fibrosis is a chronic premalignant condition that occurs due to chewing of tobacco and areca nut and has a greater tendency to progress to cancer  There is a sufficient evidence that areca nut causes progressive sub-mucosal fibrosis and tobacco increases its addictiveness and carcinogenicity.(21)The fibrosis can involve the hard palate, tonsillar fosaa, buccal mucosa and underlying muscles. In some areas of the India the incidence of submucous fibrosis is as high as 35 per 100,000 men and 29 per 100,000 women[45,32].[3,22]
In a study carried out in the UK to explore the relation between oral lesion and betal quid (paan) chewing among Bangladeshi women over the age of 40 years, revealed the presence of oral mucosal lesion in 40% of the participant and the leukoplakia was the most common disease with 25% prevalence .6 Similarly in another study conducted, in Papua New Guinea to find the relation between oral leukoplakia and bêtel quid chewing without tobacco, it was revealed that the current chewers and heavier chewers had a prevalence of oral leukoplakia of 3.8% and 4.1% respectively.
A systematic review of the studies conducted in United states and Sweden has found an association between smokeless tobacco products and the risk of fatal myocardial infarction and stroke and is explained to be without any chance. Betel nut has been found also to aggravate the cardiovascular diseases 7
Betel quid chewing is thought to be associated with asthma as well. The findings suggest that arecoline, a major constituent of betel nut, is absorbed through the buccal mucosa and exerts its broncho- constrictive properties from the circulation (14)
Non neoplastic diseases
Evidence from a systematic review of nine studies from Europe and USA has suggested a relationship of the risk of non-neoplastic oral diseases; dental caries and tooth loss with chewing tobacco.  In all the studies included chewing tobacco was significantly associated with decayed permanent tooth and decayed root surface even after adjusting for the confounders such as age, race, ethnicity, education and past-year dental visits. The risk was further increased with an increase in the number of packets used each day .Tobacco chewing also causes gum recession and loss of dental attachment which leads to dentine sensitivity and pain. Nicotine in chewing tobacco is documented to have analgesic properties and helps to overcome the pain resulting due to this dental sensitivity and as a consequence of other dental diseases. This explains the reason for experiencing oral pain by the people who want to quit and is found to be a barrier to their quit attempts..(24)
Chewing of tobacco or areca nut is associated with certain disabilities and a new name has been proposed for these .prevalent disorders;” Gutka syndrome or Areca Nut Chewer’s syndrome” Gutka syndrome is a combination of disabilities related with the chewing of areca nut and betel nut with or without smokeless tobacco It is predominant in people chewing for several years .The features of this syndrome include different degrees of fibrosis in the sub mucosal layer of the mouth and in the muscles of mastication that leads to trismus. The mucosa is white and lacks suppleness It becomes extremely temperature sensitive and is easily bruised .
After nicotine, alcohol and caffeine betel nut is the fourth highly used addictive substance. Another recent study has investigated the impact of betel nut chewing habit on pregnancy. The prevalence of low birth weight was found to be 18% in chewing mothers and it was statistically significant The reduction in the birth weight was up to 467g(30)
Among other factors, chewing tobacco is also found to be associated with the carcinoma of gallbladder.(31)
Similarly a study was conducted in southern India to evaluate the level of micronuclei (MN) in the buccal mucosa of the individuals chewing tobacco, betel quid and areca nut. It was revealed that there was not much difference in the level of MN in individuals, chewing tobacco with smoking and those who where only chewing tobacco, being 1.09+/- 1.03 and 2.00+/- 1.12 respectively.(32)
The use of betel nut in South-Asian communities is regarded as a part of their cultural identity and is further enhanced by their perception of it as a valued tradition In South Asian culture betel nut chewing is perceived beneficial and socially acceptable and is not believed to be associated with cancer and other related diseases. There is a stigma associated with women who smoke whilst there is no such stigma with using smokeless tobacco
Pressure from the family and friends is another factor stated by the women chewing tobacco. Older generation who do not believe in the health risks of betel nut chewing encourage the adolescent women to adopt this habit. In addition, the pregnant women adopt this habit to lessen their morning sickness in early pregnancy and later on maintain it to aid digestion due to its well being effect.
Paan is believed to have medicinal qualities and is thought to be effective in relieving headache and stomach ache . It is believed to freshen the breath and strengthen the gum.
One study conducted in Pakistan where chewing tobacco is the most common form of smokeless tobacco used has tried to study the attitudes and practice of smokeless tobacco users. The study revealed that 67% of the users were using it for physical and mental relaxation,59% reported the use by other family members as well. Reasons reported for its start were for relaxing and concentrating in work 67% and 39% respectively).media advertisement was another source of inspiration reported by 40% of users. 31% found it to be due to the peer pressure from friends and /colleagues. More than 40% of the respondants , mainly uneducated women, reported it to be a cheap and useful remedy to deal with common health problems.(26)
Attitudes of the women chewing tobacco have been explored in another study conducted in Papua New Guinea PNG. Women reported its use; to prevent smelly mouth (43%), it is in my custom (28%),I am addicted to it (9%), to able to work more when I am tired (8%). 28% of the women reported the use of chewing tobacco during pregnancy to reduce the morning sicknees and nausea. And 12% reported other reasons such as after meal, to relax, to be with others or socialising and for its good taste.(30)
In a study in the UK in Bangladeshi community,the main reason given for betel quid chewing was its use by everyone in the family and friends. There was a wide social acceptance of this habit by the community especially by female users. 5% of the respondents even think it acceptable for the children to chew tobacco..It was confirmed in the study that habit of betel quid chewing starts during the teen age years and the addition of tobacco in the females starts before the engagement and marriage. The habit was so frequent that 80% of the adult female were found to be engeaged in this habit..Taking few health risks was socially accepted and those who do not chew were considered deviant by the community .
Further exploring the attitudes of the Bangladeshi population regarding their perception towards the harmful effects of chewing tobacco it was found that 49% of female and 38% of male were unaware of its harmful effects of chewing paan. 23% of the participants believed that it is good for over all dental health, keeps teeth strong and helps stop pain in the gums and teeth and. It is perceived to aid digestion and keep mouth fresh. 14% of the participants also admitted that they were add
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